Wisconsin
Wisconsin Psychoanalytic Society
2323 North Lake Drive ( Seventh Floor ( Milwaukee, WI 53211
Office: (414) 291-7036(Fax: (414) 291-6394
APPLICATION FOR MEMBERSHIP
Student Associate
Psychotherapy Associate
Academic Associate
Special Associate
Affiliate Membership (candidates)
Active Membership (graduates of APsaA Institutes)
Name____________________________________________ Date__________________
Home Work
Address_______________________________ Address__________________________
City/Zip_______________________________ City/Zip__________________________
Work
Phone_________________________________ Phone____________________________
Birth Place_____________________________ Birth Date ________________________
Marital Status __________________________ Spouse’s Name ____________________
Sex ___________ E-mail Address _______________________________
Hospital Affiliations _______________________________________________________
________________________________________________________________________
Faculty Appointments _____________________________________________________
_______________________________________________________________________
DISCIPLINARY ACTIONS: Have any of the following ever been, or are any currently in the process of being denied, revoked, suspended, reduced, limited, placed on probation, not renewed, or voluntarily relinquished? If yes, please provide full explanation on a separate sheet including resolution of charges.
a) Medical license in any state Yes_____ No_____ NA_____
b) Other professional registration/license Yes_____ No_____ NA_____
c) DEA registration Yes_____ No_____ NA_____
d) Academic appointment Yes_____ No_____ NA_____
e) Membership on any hospital Medical Staff Yes_____ No_____ NA_____
f) Clinical privileges Yes_____ No_____ NA_____
g) Prerogatives/rights on any Medical Staff Yes_____ No_____ NA_____
h) Other institutional affiliation or status thereat Yes_____ No_____ NA_____
i) Professional society membership or fellowship Yes_____ No_____ NA_____
j) Professional office Yes_____ No_____ NA_____
k) Any other type of professional sanction Yes_____ No_____ NA_____
l) Have there ever been any felony criminal
charges brought against you? Yes_____ No_____ NA_____
m) Have you been the defendant in malpractice or other litigation pertaining to your professional
work? Yes_____ No_____ NA_____
n) Have you been sanctioned by any professional organization for violation of ethical standards?
Yes_____ No_____ NA_____
PROFESSIONAL LIABILITY INSURANCE
Present private carrier_____________________________________________________________________________
Have there ever been, or are there currently pending any malpractice claims, suits, settlements, or arbitration proceedings involving your professional practice? If yes, please provide a full explanation on a separate sheet. Yes_____ No_____
Please provide us with a curriculum vitae or complete the following:
EDUCATION
Institution Location Dates (From – To) Degree Received
College/
University -
Post-Grad -
Internship or
Residency -
Other Post-
Grad Study -
List professional experience chronologically (clinically, teaching, administrative, etc.):
Publications (brief)
Two references who will submit letters of recommendation.
1.
2.
________________________________________
Signature of Applicant
Wisconsin Psychoanalytic Society
2323 North Lake Drive ( Seventh Floor ( Milwaukee, WI 53211
Office: (414) 291-7036(Fax: (414) 291-6394
RELEASE OF INFORMATION
By applying for appointment to the Wisconsin Psychoanalytic Society I hereby signify my willingness to appear for interviews in regard to my application. I hereby authorize the Wisconsin Psychoanalytic Society, its staff and representatives, to consult with prior associates and others who may have information bearing on my professional competence, character, ethical qualifications, and ability to work cooperatively with others and consent to the inspection of all documents that be material to an evaluation of my professional qualifications and competence.
I hereby release from all liability all representatives of the Wisconsin Psychoanalytic Society for acts performed and statements made in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from liability any and all individuals and organizations who provide information to the Wisconsin Psychoanalytic Society in good faith and without malice concerning my professional competence, ethical qualifications, character, or other qualifications for appointment to the Wisconsin Psychoanalytic Society, and I hereby consent to the release of such information.
________________________________________ _________________________
Signature Date
The Wisconsin Psychoanalytic Society will treat this application and any information secured in connection therewith in strict confidence, preserving with all reasonable safeguards the privacy of the applicant.
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